Approach to the Critical Patient

Immediate priorities

Airborne isolation and respiratory precautions

Critical presentations requiring immediate stabilization

Massive hemoptysis

Miliary TB with ARDS

TB meningitis

TB pericarditis with tamponade

Consultation triggers

Infectious disease consultation

Pulmonology consultation

Neurosurgery and neurology consultation

History

Cardinal symptoms

Persistent cough

Constitutional symptom triad

Respiratory symptoms

Dyspnea

Extrapulmonary symptom review

Neurological

Musculoskeletal

Gastrointestinal

Genitourinary

Lymphatic

Cardiac

Exposure and epidemiological history

Contact history

Travel and immigration history

Prior TB and LTBI history

Risk factors

Immune compromise

Comorbid conditions

Social determinants

Physical Exam

Vital signs and general appearance

Vital sign pattern

Respiratory examination

Auscultation

Percussion

Respiratory pattern

Lymph node examination

Cervical lymphadenopathy

Axillary and inguinal adenopathy

Neurological examination

Meningeal signs

Fundoscopy

Mental status

Abdominal examination

Ascites

Hepatosplenomegaly

Cardiac examination

Pericardial rub

Differential Diagnosis

Pulmonary differentials

Community-acquired pneumonia

Lung malignancy

Non-tuberculous mycobacterial (NTM) infection

Lung abscess

Aspergilloma

Pulmonary sarcoidosis

Infectious differentials

Fungal infections

HIV-associated opportunistic infections

Melioidosis

Extrapulmonary differentials

Bacterial meningitis

Lymphoma

Pericardial effusion (other causes)

Laboratory Tests

Microbiological diagnosis

Sputum AFB smear microscopy

Nucleic acid amplification test (NAAT)

Mycobacterial culture

Immunological testing

Tuberculin skin test (TST/Mantoux)

Interferon-gamma release assay (IGRA)

Routine laboratory investigations

Complete blood count

Comprehensive metabolic panel

Serum uric acid

HIV testing

Liver function monitoring

Cerebrospinal fluid analysis (if meningitis suspected)

CSF parameters in TB meningitis

Diagnostic Tests

Scoring Systems

TB screening and risk stratification tools

TB meningitis scoring

Drug-susceptible TB treatment monitoring

MRI

CNS TB imaging

Spinal TB (Pott disease)

CT

Chest CT

CT abdomen/pelvis

CT head (non-contrast)

Ultrasound

Pleural ultrasound

Abdominal ultrasound

Cardiac ultrasound (echocardiography)

Disposition

Airborne isolation requirements

Inpatient airborne isolation criteria

Admission indications

Mandatory admission

Discharge criteria and outpatient management

Criteria for outpatient initiation of therapy

Transfer criteria

Transfer to tertiary centre

Mandatory public health reporting

Notification requirements

Treatment

Airborne precautions (parallel to treatment initiation)

Respiratory isolation and infection control

First-line regimen for drug-susceptible TB

Standard 6-month RIPE regimen (ATS/CDC/IDSA 2016, updated 2025)

Alternative 4-month regimen (NEJM 2022 TRUNCATE-TB / ATS 2025 update)

Directly observed therapy (DOT)

Drug-resistant TB treatment

Multidrug-resistant TB (MDR-TB): resistant to at least INH and RIF

Pre-XDR-TB (MDR + resistance to fluoroquinolone)

Adjunctive corticosteroid therapy

TB meningitis (Class I recommendation)

TB pericarditis

Endobronchial TB with airway compression

Symptom and adverse effect management

Drug-induced hepatitis monitoring and management

Peripheral neuropathy prevention

Hyperuricaemia

Optic neuritis (EMB toxicity)

Rifampin drug interactions

HIV-TB co-infection treatment

ART initiation timing in TB

Rifamycin selection in HIV-TB

Immune reconstitution inflammatory syndrome (IRIS)

Nutritional and supportive care

Nutritional support

Alcohol cessation

Special Populations

Pregnancy

Maternal and foetal risk considerations

Treatment in pregnancy

Monitoring in pregnancy

Breastfeeding

Geriatric

Atypical presentations in elderly

Drug metabolism and toxicity

Cognitive considerations

Pediatrics

Clinical presentation in children

Diagnosis in children

Paediatric dosing (weight-based)

TB meningitis in children

BCG vaccination

Background

Epidemiology

Global burden

North American epidemiology

Mortality and morbidity

Pathophysiology

Transmission

Primary infection and latent TB

Disease mechanisms

Drug resistance mechanisms

Therapeutic Considerations

Treatment duration and design principles

Hepatotoxicity risk stratification

Drug interactions with rifamycins

QTc monitoring for newer/second-line agents

Treatment success monitoring

Patient Discharge Instructions

copy discharge instructions

What you have been diagnosed with

Your medications

Directly observed therapy (DOT)

Preventing spread to others

Expected recovery

When to return to the emergency department

References

Guidelines and key sources

ATS/CDC/IDSA 2016 guidelines: Treatment of drug-susceptible TB

ATS/CDC/ERS/IDSA 2025 update: Treatment of drug-susceptible and drug-resistant TB

ATS/CDC/IDSA 2017 guidelines: Diagnosis of TB in adults and children

NTCA 2024: Guidelines for respiratory isolation for pulmonary TB

Landmark trials and systematic reviews

Xpert MTB/RIF and Xpert Ultra for TB screening

TB meningitis management guideline

Miliary TB outcomes

TB and HIV co-infection management

JAMA Internal Medicine 2018: Rapid NAAT and isolation duration

Lancet 2016 TB review

Extrapulmonary TB imaging

Emergency medicine TB review

QTc and MDR-TB drug monitoring